Youth FORWARD: scaling up an evidence-based mental health intervention in Sierra Leone

Mental and substance use disorders are leading causes of disability worldwide, affecting around 20% of the world’s children and adolescents. There is immense inequality in the distribution of skilled practitioners in mental health. World Health Organisation, The Global Burden of Disease: 2004 Update (Geneva: WHO, 2008). The level of untreated mental disorders is especially high in low- and middle-income countries, where war, violence and poverty are commonplace. Armed conflict and violence disrupt social support structures, exposing people to high levels of stress and trauma. According to the Centers for Disease Control and Prevention, 30%–70% of people who have lived in war zones suffer from symptoms of post traumatic stress disorder (PTSD) and depression. Centers for Disease Control and Prevention, ‘Global Health Protection and Security’ (https://www.cdc.gov/globalhealth/healthprotection/errb/publications/mentalhealth_affectedpopulations_pib.htm). In young people, psychological distress due to trauma exposure is often expressed in higher rates of aggression and hostility and withdrawal and social isolation. K. Amone-P’Olak, N. Garnefski and V. Kraaij, ‘Adolescents Caught between Fires: Cognitive Emotion Regulation in Response to War Experiences in Northern Uganda’, Journal of Adolescence 30(4), 2007; R. Gerson and N. Rappaport, ‘Traumatic Stress and Posttraumatic Stress Disorder in Youth: Recent Research Findings on Clinical Impact, Assessment, and Treatment’, Journal of Adolescent Health 52(2), 2013; J.Drury and R. Williams, ‘Children and Young People Who Are Refugees, Internally Displaced Persons or Survivors or Perpetrators of War, Mass Violence and Terrorism’, Current Opinion in Psychiatry 25(4), 2012. If not effectively addressed, their long-term mental health and psychosocial wellbeing may be affected. National Youth Commission, Ministry of Youth Employment and Sports, Youth Development: Sierra Leone Youth Report, 2012 (http://www.sl.undp.org/content/dam/sierraleone/docs/projectdocuments/povreduction/sl_status_ofthe_youth_report2012FINAL.pdf); Sierra Leone Ministry of Health and Sanitation, National Health Sector Strategic Plan 2010–2015, November 2009.

Mental health care in Sierra Leone

Sierra Leone has limited healthcare infrastructure, including mental health services. According to the World Health Organisation (WHO), the country, with a population of seven million people, has just two psychiatrists, two clinical psychologists, 19 mental health nurses and four nurses specialised in child and adolescent mental health. WHO Regional Office for Africa, ‘Improving Access to Mental Health Services in Sierra Leone’, 2017. Given high rates of mental health problems in Sierra Leone, ‘Global, Regional, and National Disability-adjusted Life-years (DALYs) for 333 Diseases and Injuries and Healthy Life Expectancy (HALE) for 195 Countries and Territories, 1990–2016: A Systematic Analysis for the Global Burden of Disease Study 2016’, The Lancet, 2016 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32130-X/fulltext). the constraints on the health system and the government’s limited capacity, alternative delivery platforms for evidencebased psychosocial interventions are critical. The government recognises the need to address the effects of trauma on the mental health and daily functioning of young people exposed to violence and adversity, and recent government and nongovernment investment in youth development programming creates a favourable context for integrating mental health interventions into existing employment programmes.

YOUTH Forward and the Youth Readiness Intervention

Youth FORWARD (Youth Functioning and Organizational Success for West African Regional Development) is a coordinated plan to establish research partnerships and a regional hub for scaling up evidence-based mental health interventions for young people in West Africa. In Sierra Leone, it is providing the framework for scaling up the Youth Readiness Intervention (YRI), a mental health intervention for war-affected youth. The YRI builds on 15 years of research on the effects of war, violence and other post-conflict adversity on the mental health of young people in Sierra Leone, starting immediately after the end of the brutal civil war in 2002 with the Longitudinal Survey of War Affected Youth (LSWAY). The study – the first of its kind in Sub-Saharan Africa – found high levels of mental health needs linked to past exposure to violence, manifested for example in poor emotional regulation and anger, depression and hopelessness. The study also explored protective factors, such as education, social support and community and family acceptance.

Preliminary research to inform the development of the intervention also highlighted gaps in mental health services for young people. Many programmes, for example, focused on classic symptoms of PTSD, but few focused on the anger and interpersonal difficulties young people were suffering. To address these issues, the team sought input from a range of local stakeholders. Focus groups with community leaders, young people and professionals highlighted the need for an intervention that could be delivered in communities by lay mental health workers. Interviews with mental health professionals, youth organisations, teachers, health care workers, religious and community leaders, officials in government ministries and Community Advisory Boards provided valuable input in the development of the intervention. The study team were also careful to incorporate common elements of evidence-based treatments that had been shown to work well in diverse settings and cultures.

The YRI incorporates two strategies: a common-elements approach, which adapts treatment strategies and techniques to fit new contexts and problems; and a transdiagnostic approach, which applies treatment across the full range of mental illness, rather than targeting a specific diagnosis. The YRI’s six components are delivered in three phases common in trauma-informed interventions: stabilisation, integration and connection. Stabilisation: youth receive psychoeducation about the impacts of trauma, and begin to develop initial coping skills; integration: youth explore their own struggles with anger and maladaptive coping as a group; connection: youth use self-awareness to practice skills essential to navigating their environment and managing interpersonal relationships. The intervention is divided into 12 sessions meant to be delivered over 12 weeks, with each phase building on the last. A group format encourages peer-to-peer learning and deepens social connections. The YRI can be delivered by lay counsellors, and does not require mental health professionals or specific educational requirements. The approach prioritises intensive training, supportive supervision administered in individual and group formats and fidelity monitoring via audio-taped intervention sessions and direct observation to bolster counsellors’ skills, reinforce key YRI components and ensure the intervention is being delivered as intended. Following testing in a school, participants reported significant improvements in emotion regulation, social attitudes and behaviours and social support compared to the control group. Eight months after the intervention, YRI participants were more likely to stay in school, had better attendance and their classroom behaviour had improved.

The YRI and youth employment

Our current study will integrate the YRI within the youth Employment Promotion Programme (EPP) established by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). The EPP responds to market demand to ensure that young people obtain the qualifications they need for employment or self-employment. It consists of three training modules intended to strengthen skills relevant to the labour market, increase income and promote resilience to economic shocks. Our research will look at a range of implementation factors, including feasibility, barriers and facilitators, alongside a clinical effectiveness evaluation to measure changes in participants’ mental health, notably emotion regulation.

Translating this research into effective implementation is filled with challenges. While many promising practices and programmes have been developed, they often fail to improve health outcomes, and over time key programme elements may become ineffective. Implementation models typically rely heavily on remote expertise and do little to develop local knowledge. Organisations often experience high levels of staff turnover because they do not have consistent funding, making it difficult to maintain institutional knowledge and sustain the intervention over time.

To remove the need for remote expertise for training and monitoring, our model uses a collaborative interagency approach to develop a core of local experts – a seed team – to provide training, coaching and support. Team members come from a variety of organisations concerned with vulnerable youth in Sierra Leone, creating cross-agency collaboration and expanding institutional knowledge of YRI. Through a cascading process, the seed team will become an expert team, and then train, monitor and supervise a new seed team for additional EPP modules in a larger scale-up study. Through this process, seed team members become YRI expert facilitators, as well as developing critical skills related to collaboration, leadership, communication and quality improvement. Using these inter-agency collaborative teams and partnering with different non-governmental partners is a major innovation, and we hope that the expertise gained through this approach will result in broader investments in and commitments to evidence-based programming related to vulnerable youth in Sierra Leone.

To conclude, we share some core considerations for investments in research. First, concerted effort is required to study the effectiveness of interventions, and how mental health and psychosocial programming can contribute to the development of longer-term and sustainable systems of health and mental health care, in both low- and high-income settings. Second, ethical conduct and the safety of children, youth and local research staff must be prioritised. In addition to obtaining appropriate approval from local and international ethics review committees, community advisory boards can help ensure ethical implementation and the appropriate dissemination of findings. Third, research and interventions should be contextualised. Attention must be paid to the setting, including risk and protective factors at the individual, family, peer, community and societal and cultural levels. In work with young people, a child’s developmental progress and growth must also be considered. Fourth, we strongly encourage participatory approaches, locally defined priorities and collateral respondents. Psychosocial interventions should be based on locally identified needs, rather than externally imposed services or researchers’ assumptions, identifying priorities through community-based participatory approaches and collaboration with local service providers and Community Advisory Boards. Other considerations include addressing limited human resources for health, incentives, training, supervision and professional development for staff, financing and policy structures and strategies for monitoring and improving quality.

Theresa S. Betancourt is Salem Professor in Global Practice and Director of the Research Program on Children and Adversity at the Boston College School of Social Work.